The remarkable success stories of these two smokers, suffering from depression, requires justification. The widely acknowledged beneficial role of pharmacotherapy in smoking cessation is likely to be due to their ability to address the physical component of tobacco dependence.
However, taking pills or patches for nicotine addiction is unlikely to resolve the psychological components (cogni- tive, social and behavioural) associated with tobacco dependence. As a matter of fact smoking is much more than the addicting effect of nicotine; the smoking habit is also the rituals that each smoker associates with his/her habit
. For example, smoking gestures (e.g. the tactile sensations of the cigarette and other sensations associated with smoking gestures) can play an important part in tobacco addiction as they are usually performed in a pre- dictable, ritualistic manner that act to signal a mental context shift. When the smoker stops smoking, those rituals are no longer there, but the need for the ritual still exists and this is an important cause of relapse. Smoking cessation products cannot replace the rituals associated with the act of smoking. Counselling for smoking cessation is intended to help smokers in coping with this important aspect of their life by implementing personalized replacement rituals, but even counselling for smoking cessation lacks high levels of efficacy
Therefore, it is likely that the smokers described in our case series coped successfully with the psychological components associated with their tobacco dependence by using a device resembling a cigarette, which—although being mainly designed for the purpose of nicotine deliv-ery to the respiratory system—it has the additional advantage of being a valid substitute for the tactile sensations of the cigarette and other sensations associated with smoking gestures.
Although the present findings cannot be generalized, high quit rates would be desirable in a population that generally respond poorly to smoking cessation efforts like smokers suffering from depression.
Larger con- trolled studies are needed to confirm this interesting findings, particularly for those smokers for whom handling and manipulation of their cigarettes play an impor- tant part of the ritual of smoking.